My employer’s health plan denied a $22K claim. What should I do?
Dear Toni: My oncologist’s office manager advised me that because I am over 65 I may want to apply for Medicare and leave my employer health insurance. She said my health plan denied my claim for my cancer treatment because the plan considers it experimental and will not approve this care.
The treatment costs me over $22,000 per month, which I am paying from my 401(k), draining what I need to retire. I am not retiring from my job but using the 12 weeks of vacation time I have, so I do not lose my current full-time salary.
She said she knows Medicare will pay and provide the care I need, because she currently has patients on original Medicare with a supplement. She files their claims without a problem.
I need to know how to begin my Medicare benefits as quickly as possible. — Bart, Memphis, Tenn.
Dear Bart: A health care professional told me many new cancer procedures are not approved by individual and employer group health insurance plans. But the doctor said these procedures are generally approved with original Medicare.
Enrolling in original Medicare past 65, while employed and leaving employer benefits, is the same whether:
■ You have health issues not covered by an employer health plan: You (or your spouse) are still working with health issues (like Bart) and the employer health insurance plan is not covering the doctor’s procedure. Even though you are not retiring, you need to enroll in Medicare.
■ You’ve been laid off: You (or your spouse) are laid off and need to enroll in Medicare.
■ You’re retiring past 65: You (or your spouse) decide to retire past 65 and need to enroll in Medicare.
The process to enroll in Medicare past 65 must be followed correctly:
1. A Request for Employment Information (CMS-L564) must be signed by your employer’s human resource representative for you and your spouse if covered by company benefits. The Application for Enrollment in Medicare Part B (CMS-40B) must be filled out and signed by you (and your spouse if also enrolling in Medicare). These two forms are available at the Social Security website (SSA.gov).
2. Write “special enrollment period” on form CMS-L564.This informs the Social Security agent processing the form that you are signing up at the right time and prevents a Medicare Part B penalty. If you have had two or more jobs since turning 65, each of those companies must sign a form.
3. Make copies of your completed CMS-40B, stating which month your Medicare Part B should begin, and your CMS-L564 form.
4. Take your original forms to a local Social Security office for your Medicare to begin. Keep copies of the paperwork in case it is lost.
Toni King is an author and columnist on Medicare and health insurance issues. If you have a Medicare question, email info@tonisays.com or call 832-519-8664.